DELIRIUM

Studies of Pharmacologic Delirium Treatments Show Promising Results

 

 

Encouraging data for the effectiveness of medications for delirium—especially for prevention of the disorder—were found in a systematic review of literature on the subject. “Pharmacological Treatments of Non-Substance-Withdrawal Delirium: A Systematic Review of Prospective Trials” was published online in AJP in Advance.
Delirium can accompany a number of medical conditions and hospital-based treatments. Researchers at Icahn School of Medicine at Mount Sinai and the Clinical Neuroscience Center at Pilgrim Psychiatric Center in New York reviewed published prospective trials of potential pharmacological interventions for preventing and treating delirium. The pharmacological strategies reviewed showed greater success in preventing delirium than in treating it. Significant delirium prevention effects were associated with haloperidol, second-generation antipsychotics, iliac fascia block, gabapentin, melatonin, lower levels of intraoperative propofol sedation, and a single dose of ketamine during anesthetic induction and with dexmedetomidine, compared with other sedation strategies for mechanically ventilated patients.
“Given the association between delirium and increased hospital-based complications, including mortality, and long-term complications such as cognitive decline and need for custodial care, there is an imperative to prevent the appearance of delirium and, once present, to treat it with the intention of both improving the immediate clinical picture and potentially improving long-term outcome,” the researchers said. “The preponderance of evidence suggests greater success at preventing delirium with the pharmacological strategies reviewed here than treating delirium once it develops.”
“These promising results warrant further study with consideration of the methodological weaknesses and inconsistencies of studies to date,” they acknowledged.

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PREGNANCY RIGHTS IN THE WORKPLACE

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PREGNANCY RIGHTS IN THE WORKPLACE

 

Employers have many questions regarding employee pregnancy issues. Here is an outline of the basic things to keep in mind about the rights of a pregnant employee:

 

Fewer than 15 employees:

  1. If a business has fewer than 15 employees (counting anyone who works for the business, performing services for pay, for each working day in each of twenty or more calendar weeks in the current or preceding calendar year), it is not covered by any employment law relating to pregnancy or disability, and the business would be free to handle the situation in any way it deems appropriate. Of course, a business not covered by such laws would still want to treat its employees as fairly and consistently as possible, if for no other reason than to minimize complaints, unnecessary turnover, and the risk of unfavorable publicity. Businesses with 15 or more employees should see the comments below.

15 or more employees:

  1. If the business has 15 or more employees, it is covered by state and federal pregnancy and disability discrimination laws, which require non-discriminatory treatment of pregnant employees and reasonable accommodation for employees with disabilities. Disability laws can come into play for a pregnant employee if the pregnancy becomes complicated and results in something that can turn into a disability, such as gestational diabetes.

  2. From a practical standpoint, avoiding liability for pregnancy discrimination involves ensuring that employees are not adversely treated due to pregnancy, making reasonable accommodation for pregnant employees, and extending the same benefits and treatment toward them as the company extends to other employees who have medical conditions. Pregnant employees do not need to be treated any better than other employees with medical conditions, but need to be treated at least as favorably.

  3. If an employee claims that she cannot do certain duties due to being pregnant, the company has the right to require her to medically document such claims. Have the employee obtain a statement from her doctor showing clearly which duties of her job she can perform, which duties she cannot perform, and what accommodations might be necessary to enable the employee to continue working. Documentation requirements like this should be applied consistently and fairly to anyone who asserts a medical difficulty in doing their job functions.

  4. Reasonable accommodation is something that the company can do, without undue hardship to the business, that allows the employee to work and manage any periods of leave.

  5. Among other things, reasonable accommodation could include things such as redesigning job duties temporarily, furnishing health or safety aids, and extending a reasonable amount of maternity leave.

  6. Regarding job duties for pregnant employees, it is important to act on the basis of sound medical information, rather than company officials’ own ideas about what might be too risky for a pregnant woman to do. In UAW, et al, v. Johnson Controls, 499 U.S. 187, 111 S.Ct. 1196 (1991), a case involving a policy prohibiting women of child-bearing age from working in positions that would potentially expose them to lead in the battery manufacturing process, the Supreme Court ruled that the risk of harm to a pregnant employee or her fetus is not a legal basis for denying a job to a woman and commented: “If, under general tort principles, Title VII bans sex-specific fetal-protection policies, the employer fully informs the woman of the risk, and the employer has not acted negligently, the basis for holding an employer liable seems remote at best. Moreover, the incremental cost of employing members of one sex cannot justify a discriminatory refusal to hire members of that gender.” Thus, acting on the basis of medical information, obtaining informed consent from the pregnant employee for her performance of potentially risky job duties, and maintaining a safe workplace would generally be the best way to proceed.

  7. Concerning the length of maternity leave, there is no hard-and-fast rule in the statute or in regulations. However, based upon EEOC guidance and court cases, it would appear that at a minimum, a covered employer can be expected to allow at least two weeks of unpaid or paid leave for pregnant employees. Paid leave is not required unless it is promised in a written policy or agreement, and unless others who miss work for medical reasons are allowed to use available paid leave for medical absences. The best practice is usually to allow pregnant employees to apply their available paid leave as long as it lasts.

  8. The larger the company is, the longer the time is that the EEOC or a court might consider reasonable in terms of duration of leave. Employers at the lower end of coverage, i.e., between 15 and 25 employees or so, can usually get away with two weeks or so, but larger companies might be expected to increase the time somewhat. In such situations, a neutral absence control policy can help. A basic sample of such a policy appears at the following link: http://www.twc.state.tx.us/news/efte/neutral_absence_control_policy.html.

  9. Another thing to keep in mind is the issue of notice. In this case, that would be notice of her intent to return to work. Some companies, but not all, have policies requiring employees on extended leaves of absence to check in at stated intervals regarding their return-to-work status. If a company has such a policy, and the employee has not adhered to it, then the company would likely want to see what the policy says about employees who fail to keep in touch as the policy requires.

  10. Pregnancy leave can be related to other forms of medical leave, such as FMLA (for employers with 50 or more employees) and disability leave. Generally speaking, if two or more leave-related laws apply to a particular employee, the company should determine which law affords the greatest degree of protection for the employee and apply that result. Concerning the way that various medical leave-related laws fit together, see the following topic in this book: http://www.twc.state.tx.us/news/efte/medical_leave_laws.html.

  11. Benefit continuation during maternity leave should be handled the same as it is for anyone else who goes on leave for other reasons.

  12. If the company eventually arrives at the point where it can no longer readily accommodate the absence, and assuming that such action would not violate company policy or any individual employment agreement with the employee, it would be a good idea to advise the employee in writing that unless she is able to return to her duties by a stated deadline, the company will not be able to guarantee that it can continue to hold her job open and may have to replace her.

  13. If the employee is ultimately laid off due to medical unavailability for work, and she files an unemployment claim, the company might consider responding to the claim with an explanation that the layoff was due to the claimant’s medical unavailability for work, i.e., it was a medical work separation, and that the employer’s account should be protected from chargeback of any benefits the claimant might receive. See the section headed “Medical Separations” in the following article in this book: http://www.twc.state.tx.us/news/efte/ui_law_qualification_issues.html.

  14. In the event of a layoff for such a reason, try to end the work relationship on as positive a note as possible. Let the employee know that she is welcome to check back with the company once she is able to return to work, and that the company will be glad to consider her for any vacancy that might exist at the time. The company does not promise her a job thereby, but it sounds positive and will help dispel any notion that the company does not want her back.

  15. Since any kind of discrimination claim can be a very serious matter, it could be well worth investing in an hour or two of an employment law attorney’s time regarding the company’s position in such matters, prior to taking any action with respect to a pregnant employee, just to help ensure that the company is not missing some kind of important issue.

  16. The EEOC’s official fact sheet on pregnancy discrimination law is at the following link: http://www.eeoc.gov/laws/types/pregnancy.cfm.

  17. The main EEOC regulation dealing with pregnancy and maternity leave is here: http://edocket.access.gpo.gov/cfr_2006/julqtr/29cfr1604.10.htm.

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Children

A child is smacked for knocking over a drink (image posed by model)

A child is smacked for knocking over a drink (image posed by model). Photograph: Murdo Macleod for the Guardian
Pets have more legal protection than children, whose parents should be banned from smacking them, according to the Children’s Commissioner for England.

Maggie Atkinson said it was her personal view that the law gives pets and adults more rights to be protected from violence than children, and she would like to see a total ban, with parents facing criminal action for corporal punishment.

Current rules make it illegal for a parent to smack a child if it leaves a bruise, but permit a lighter smack or “reasonable chastisement”.

Atkinson said: “Personally, having been a teacher, and never having had an issue where I’d need to use physical punishment, I believe we should move to ban it. Because in law you are forbidden from striking another adult, and from physically chastising your pets, but somehow there is a loophole around the fact that you can physically chastise your child.”

Tottenham MP David Lammy said early last year that legislation surrounding the smacking of children needed to be relaxed so working-class parents could instil discipline in their homes without fearing prosecution. He claimed Labour’s 2004 decision to tighten up the smacking law was partly to blame for last summer’s riots, which erupted in his north London constituency.

Atkinson, who has two adult stepchildren, said that despite her strong feelings about the issue, her office was not planning to fight for a ban next year because in the current climate such a move would be “running up a blind alley”.

Her comments were likely to reopen the debate about what constituted reasonable punishment of children, the newspaper said.

She added: “It’s a moral issue. The morals are that, taken to its extreme, physical chastisement is actually physical abuse and I have never understood where you can draw the line between one and the other. Better that it were not permitted.”

Schizophrenia

Study Finds Genetic Overlap in Schizophrenia and Cognitive Ability

 

 

Subtle cognitive impairment has been found in several research studies in relatives of individuals with schizophrenia, suggesting the possibility of genetic overlap between schizophrenia and cognitive aptitude. To further evaluate this apparent association, researchers from New York’s Zucker Hillside Hospital and Feinstein Institute for Medical Research conducted the first study investigate whether genetic markers of cognitive impairment intersect those linked to schizophrenia. The findings were published in last week’s Molecular Psychiatry.
The researchers compared single-nucleotide polymorphisms (SNPs) from more than 5,000 subjects who had a diagnosis of cognitive impairment or schizophrenia with those from individuals without a mental illness diagnosis. Levels of genetic overlap were measured by polygenic scores, a sum of trait-associated alleles between two or more chronically ill populations as well as a predictor of an individual’s genetic risk for certain diseases. The researchers reported that polygenic scores indicated that schizophrenia was associated with lower cognitive ability than was the case for controls with neither cognitive impairment nor schizophrenia. In addition, multiple SNPs from cognitively impaired subjects significantly overlapped in trait-associated alleles that were found in subjects with schizophrenia.
“Schizophrenia has long been recognized to have a cognitive component,” Anil Malhotra, M.D., senior author and director of psychiatry research at the Zucker Hillside Hospital, told Psychiatric News. “We have demonstrated that the genes that influence cognitive ability also influence schizophrenia, and, as before, clinicians should be attentive to the very real problem of cognitive impairment in schizophrenia.”

Liver and antidepressant

Liver Injury Associated With Antidepressant Use Requires Quick Action

 

 

Although uncommon, drug-induced liver injury (DILI) from antidepressant drugs does rarely occur and may be irreversible, and clinicians should promptly discontinue antidepressant drug use when liver abnormalities appear, according to the study “Antidepressant-Induced Liver Injury: A Review for Clinicians,” which appears online in AJP in Advance.
French researchers conducted a PubMed literature search for publications from 1965 onward related to antidepressant-induced liver injury. The search terms were “liver injury,” “liver failure,” “DILI,” “hepatitis,” “hepatotoxicity,” “cholestasis,” and “aminotransferase,” cross-referenced with “antidepressant.”
They found that 0.5% to 3% of patients treated with antidepressants may develop asymptomatic mild elevation of serum aminotransferase levels. Liver damage is in most cases idiosyncratic and unpredictable, and it is generally unrelated to drug dosage. The antidepressants associated with greater risks of hepatotoxicity are iproniazid, nefazodone, phenelzine, imipramine, amitriptyline, duloxetine, bupropion, trazodone, tianeptine, and agomelatine. The antidepressants that seem to have the least potential for hepatotoxicity are citalopram, escitalopram, paroxetine, and fluvoxamine.
Aminotransferase surveillance is the most useful tool for detecting DILI, Moreover, early detection and prompt drug discontinuation are critical, the researchers stated. “Surveillance of liver function in clinical trials and careful evaluation of reported abnormalities could make a major contribution to the early detection of antidepressants associated with a high risk of causing DILI. Finally, further research is required before rigorously founded recommendations can be established for clinical practice.”

Anxiety

High Anxiety Levels May Increase Risk of Stroke, Study Finds

 

 

Prolonged elevated anxiety levels may increase one’s risk for stroke, according to a study published in yesterday’s edition of the journal Stroke. Researchers from the University of Pittsburgh and Harvard School of Public Health evaluated more than 6,000 Americans aged 25 to 74 who had not experienced a stroke prior to study initiation. Participants were required to complete questionnaires that measured anxiety and depression levels, and they were then followed for up to 22 years. Stroke occurrences in the subjects were determined through death certificates and medical records. The results showed that highly anxious individuals were 33 percent more likely to experience a stroke when compared with their less-anxious counterparts. This risk persisted after controlling for depression symptoms.
“Most of the focus [on mental health and stroke] up until this point has been on depression. These findings underscore the importance of also considering anxiety when considering cardiovascular diseases,” said Rebecca Thurston, Ph.D., senior author of the study and an associate professor of psychiatry at the University of Pittsburgh. “These findings encourage practitioners to assess and treat anxiety, as well as to reconsider popular notions such as ‘worried well’—this worrying may not make us so well.”
Because even a modest increase in anxiety was associated with an increase in stroke risk, the researchers noted that more education and awareness on managing anxiety is of great importance

Children

Children’s Mental Health Needs Following Disaster Said to Require Special Attention

 

 

Children are frequently caught up in natural or man-made disasters, but the specific postdisaster mental health needs of this vulnerable population are too often overlooked in disaster-preparedness planning, according to a report of a recent workshop by the Institute of Medicine. About 1 in 3 individuals (including children) who survive a disaster are at risk for developing a new psychiatric disorder afterward; however, parents may discount symptoms in their children as understandable reactions to the disaster, or children may suppress their complaints out of fear of being considered “abnormal” or because they don’t want to further burden their parents at a difficult time.
Thus, school personnel, primary care clinicians, and mental health professionals should know about mental health screening and triage protocols, such as the PsySTART Rapid Mental Health Triage and Incident Management System, available to identify and refer children who need help. “Adults who work with children should understand the likely reactions to disaster and know techniques to help them cope,” said the report, quoting pediatrician David Schonfeld, M.D., director of the National Center for School Crisis and Bereavement at St. Christopher’s Hospital for Children in Philadelphia.
“Triaging high-risk children, while also taking into account important trauma histories and exposure to other incidents can be instrumental in ensuring that children progress through a recovery of timeline along with their peers, and return to their normal baseline after an event or reach further growth potential,” the report concluded.